In primary hyperparathyroidism greater than 90% of cases are caused by an abnormality in one single gland (parathyroid adenoma). A parathyroid scan (Sestamibi scan) or other imaging (ultarsound or CT Scan) can often times find this one abnormal gland. This allows us to take a minimally invasive approach to this disease, by removing this one gland though a small incision, measuring between 1.5 to 2 cm or less then an inch (Fig. 7 Parathyroidectomy Incision). Despite the small size of incision, in expert hands finding the parathyroid gland is usually not challenging (Fig. 8 Parathyroid Gland & Recurrent Laryngeal Nerve & Fig. 9 Parathyroid Adenoma).
We also use intra-operative rapid PTH testing to confirm an appropriate decline in the level of PTH hormone. The PTH level is checked right before surgery and then again in the operating room after the abnormal parathyroid gland is removed; when the PTH level falls, it shows us that the abnormal gland that was producing too much PTH has been removed. By doing this our surgeons can be certain that your surgery has been successful, immediately in the operating room.
Additionally, in cases of double adenoma or hyperplasia that was not recognized before the surgery, the PTH level does not fall, leading us to the other abnormal glands that need to be removed. This is as opposed to finding out after surgery that the calcium and PTH levels are persistently high, and that the patient needs a second surgery.
Due to the ease of surgery for the patient, it can be done under loco-regional anesthesia, with patient awake but sedated. This may be done in cases where the patient’s health condition precludes general anesthesia, or if the patient prefers not to have general anesthesia.
Parathyroid hyperplasia or four gland disease requires treatment of all four glands (total or subtotal parathyroidectomy), with possible re-implantation of part of one gland in the muscle, or leaving half of one gland (with its blood flow intact) to take over the function of maintaining the body’s calcium balance. Due to anatomic variation in the location and the number of parathyroid glands (three to six in 6% of people) Intra-operative rapid PTH testing, is crucial in making sure these patients are completely treated (Fig. 10 Superior Parathyroid Locations & Fig. 11 Inferior Parathyroid Locations).
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Fig. 11 Inferior Parathyroid Locations
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